Monthly Archives: January 2003

Under pressure from lawmakers and consumer advocates, the hospital industry said it would consider making broad price cuts for the uninsured — provided the federal government approves. The announcement by the American Hospital Association included a stark admission that some hospital billing and collections practices are unfair to needy patients. But even as some big hospitals scramble to curtail their most aggressive tactics, such as putting liens on debtors’ homes, the trade group is also blaming much of the problem on Medicare. In a letter delivered Tuesday to the Department of Health and Human Services, the hospital group said Medicare regulations “make it far too difficult and frustrating” for hospitals to reduce prices for people who can’t afford health care. The letter asks the agency, which oversees Medicare, the federal health-care program for the elderly, to change or clarify its rules so that hospitals “have the ability to do what they can to respond to the needs of these patients.” In a document filed in support of its letter, the trade group also said it would urge its 4,800 member hospitals to adopt a set of voluntary guidelines on billing and collections. At the heart of the issue is the hospitals’ common practice of charging full listed prices to the nation’s 43.6 million uninsured patients. Meanwhile, other patients enjoy steep discounts negotiated on their behalf — either by private insurers and HMOs or by government programs such as Medicare and Medicaid, the federal-state program for the poor. In some areas, the hospitals’ official charges amount to several times the discounted rates. Adding to the problem for the uninsured, many hospitals have become more aggressive in seeking payment of these bills. Hospitals have placed liens on debtors’ homes, garnisheed wages, seized bank accounts and, in some cases, sought the arrest of debtors who miss court dates, a practice known in some states as “body attachment.” The letter, addressed to Secretary of Health and Human Services Tommy Thompson, marks a turning point for an industry that has been reluctant to acknowledge that its financial practices contribute to the plight of the uninsured. In a series of articles this year, The Wall Street Journal has examined hospitals’ aggressive billing and collections methods, including charging uninsured patients full listed prices while other patients get discounts.

The hospitals contend the pricing disparity is the result of Medicare regulations requiring hospitals to maintain a uniform list of charges for every treatment and service they administer — even for patients who aren’t covered by the program. The hospitals claim they can’t offer unilateral reductions in these charges to categories of people, such as uninsured patients, without fearing they may be violating Medicare rules. In a longer document accompanying its letter, the hospital group also blamed Medicare for some of their collections practices, claiming the program’s rules “create a very strong presumption that hospitals must use aggressive efforts to collect from all patients,” including sending collection letters, making telephone and personal contacts, and initiating court action. It isn’t clear whether Medicare’s complex rules are as inflexible as the hospitals claim. Tom Gustafson, deputy director of the Center for Medicare Management, a Medicare division, said the rules allow hospitals to offer poor people discounts from listed charges “on a patient-by-patient basis, and it has to require verification of the financial need of each patient.” Mr. Gustafson said Medicare officials need to study the hospital group’s concerns and added: “We are prepared to think about, to consider and to learn about this situation in greater detail.” A spokesman for HHS Secretary Thompson said the secretary would consider the issues the industry was bringing to his attention.

Over the past year, lawmakers, labor unions and patient advocates have increasingly urged hospitals to make changes in the way they bill and collect from patients. The House Subcommittee on Oversight and Investigations this summer launched a probe into hospital billing and collections, and plans to hold hearings early next year. “In the worst instance, hospitals simply apply outrageously high charges — higher than what Medicare pays, higher than private payers — and then will relentlessly and sometimes mercilessly pursue poor people for their money, even to the point of having them arrested,” said Rep. James Greenwood, a Pennsylvania Republican and chairman of the subcommittee. A new Connecticut law, which went into effect in October, makes it harder for hospitals to sue patients and to seize their bank accounts or place liens on their homes. That law also slashes interest rates charged on patient bills to 5% from 10%. In Illinois, state legislators are weighing laws that would end what they call “discriminatory pricing,” the practice of billing uninsured patients more than insured patients — on the theory that uninsured people tend to be minorities against whom it is illegal to discriminate. In New York, a pending bill in the state legislature would limit the amount hospitals could bill poor uninsured patients to no more than the sum Medicare or private insurers would pay, whichever is larger. Now the hospital industry is pushing for big changes in Medicare. Its letter requested that Medicare issue a “safe harbor” rule enabling hospitals to discount or waive charges for the uninsured without risking trouble with the program. The association is also asking Medicare for a new advisory process under which hospitals could quickly get rulings on when and how they could discount rates to the uninsured.

If Medicare makes these changes, “hospitals will gladly and willingly deconstruct the terribly frustrating system that ties their hands and is ruining their reputations,” said Richard Wade, a spokesman for the American Hospital Association. The Medicare rules requiring hospitals to maintain lists of their charges date to the establishment of the program in the 1960s. The original purpose of the uniform charges was to prevent hospitals from charging some classes of patients more than others, or overcharging the Medicare program. That made sense in the early years of Medicare, when hospital charges generally reflected the cost of providing care plus a modest profit. In the 1980s, as powerful HMOs emerged, they began demanding their own discounts from the hospitals’ listed charges. Hospitals in turn began boosting their charges, in part as an effort to set a higher starting point for negotiations. Lost in the mix were uninsured patients, who continued to be billed as they always were, unaware of the discounted rates and with no one to negotiate on their behalf. Mr. Gustafson, the Medicare official, conceded that the listed charges “had a lot more meaning 20 or 30 years ago, before managed care.”

For uninsured patients, the impact of being billed at full hospital charges can be harsh. Last year, Judith Geva, an uninsured 51-year-old small-business owner, had an emergency hysterectomy at North Shore University Hospital in Manhasset, N.Y., part of the North Shore-Long Island Jewish Health System. She received a hospital bill for full charges of $21,508. For the same procedure, which requires a three-day stay, Medicaid pays the hospital $8,456, and Medicare pays $7,600, according to the hospital and the government programs. The hospital said private insurers and HMOs in the area would reimburse it at roughly the same rate as Medicare. Ms. Geva says her home software business had suffered a downturn and she couldn’t afford to buy insurance or pay her hospital bill. She says she had applied for Medicaid but was turned down, in part because she owns a house. In February, North Shore turned her bill over to collections, and the hospital sued her three months later. Ms. Geva says she e-mailed legislators and searched the Internet in vain seeking assistance, until she found the Long Island Health Access Monitoring Project, a group that helps the uninsured. A retired physician in the group called a hospital executive, and Ms. Geva’s bill was cut by more than half, to $10,000 — an amount still higher than what any government program or private insurer would have paid. Ms. Geva says she charged most of the bill on her Discover card, and is trying to pay it back, with interest. She adds that she now has health insurance.
Terry Lynam, a spokesman for North Shore-LIJ, said Ms. Geva had been billed full charges in keeping with Medicare regulations, and that the hospital refers bills to collection agencies after 60 days. “The collection efforts weren’t heavy-handed,” he said. Mr. Lynam added that North Shore-LIJ “recognizes the flaws in the billing process” and is planning to implement a far-ranging new financial-aid plan. Starting in February, the hospital said, uninsured patients and those in families below a certain income ceiling would qualify for sliding-scale reductions from Medicaid rates, which are already much lower than the hospitals’ listed charges. Mr. Lynam said the hospital believes this plan will pass muster with Medicare.

Other hospitals are planning sweeping changes to their billing practices. Ascension Health, the nation’s largest Catholic hospital chain, said it will offer free care to every uninsured patient whose income falls below the federal poverty level, provided they don’t qualify for government aid. (The poverty level is $8,980 for an individual, and $18,400 for a family of four.) Poor patients with an income up to twice the poverty level also would be eligible for discounts. The amount of the discounts would be left to the discretion of individual hospitals in the 67-hospital Ascension system, which is based in St. Louis, Mo. Douglas French, chief executive of Ascension, said the chain also plans to seek Medicare approval for even more dramatic price cuts. Ascension wants to bill all uninsured patients — rich and poor — at the same discounted rates its hospitals get from HMOs and insurers. Under that plan, “basically, nobody gets [full] charges,” said Bruce Vladeck, a member of Ascension’s board of directors. However, Mr. Vladeck, a former head of Medicare, said he isn’t sure the unilateral discount for uninsured patients would pass muster with his old agency. A major for-profit hospital chain, HCA Inc. of Nashville, Tenn., said it struggled for months to craft a program of price breaks for uninsured patients that would satisfy Medicare rules. HCA’s plan, launched this fall, offers free care to uninsured patients who earn up to twice the federal poverty level. HCA also offers a sliding scale of discounted fees to patients who earn as much as four times the poverty level. “It wasn’t casually, ‘Oh, we will do this,’ ” said Jeff Prescott, an HCA spokesman. “We sat internally for more than a year trying to craft what could be done within the existing environment.” A Medicare spokesman declined to comment on the HCA plan.

Meanwhile, another large, for-profit chain, Tenet Healthcare Corp. of Santa Barbara, Calif., said it hasn’t been able to move forward on its own discounting plan, which involved billing low-income, uninsured patients at the same discounted prices it gets from HMOs. Medicare raised questions on the plan, and the company said it is awaiting a legal opinion from the Inspector General of the Department of Health and Human Services. In the meantime, Tenet says, it has drastically curtailed lawsuits against uninsured debtors and restricted the use of liens, eliminating them entirely for patients whose home is their only asset. In its appeal to regulators, the American Hospital Association said it was urging its members to adopt “fair billing and collection practices,” such as requiring hospitals to better monitor their collection agencies. However, the guidelines stopped short of barring hospitals from using specific collections tactics such as putting liens on houses or seeking the arrest of debtors. Responding to criticism that hospitals frequently don’t tell patients that charity care or financial aid is available, the guidelines urge institutions to offer financial counseling and to make that counseling “widely known.” The hospital group also urged its members to lift the veil of secrecy that has surrounded their lists of charges, stating that hospitals should make available for public review “specific information in a meaningful format about what they charge for services” to help patients understand their bills. Mr. Wade, the group’s spokesman, added: “We have to be much more transparent about our charges.”

Respected novelist and playwright Peter Tinniswood has died at the age of 66 following a long battle with cancer. The writer was diagnosed with oral cancer in 1995 and had undergone surgery to have his larynx removed.

Tinniswood was responsible for bringing many memorable characters to radio and television. One of his best-remembered characters was Uncle Mort, an indomitable northerner who contracted cancer in the screenplay I Didn’t Know You Cared.

Several of the television and radio plays written by Tinniswood attracted a devoted following. Perhaps his best-known works were Tales from a Long Room, and its sequel, More Tales from a Long Room, which told stories about cricket, one of Tinniswood’s life-long passions.

His novels were produced on television, radio and the stage. Most recently he worked on the small screen adaptation of HE Bates’ Uncle Silas, which stars Albert Finney. Born in Liverpool, Tinniswood grew up in Sale, Greater Manchester, England where he lived above the dry-cleaners run by his mother. As a young boy he would sit under the counter among the dirty laundry, listening to customers’ conversations. “It was like live radio,” he said “it sharpened my ear for dialogue…I became a good mimic.” He began his working life as a journalist, writing fiction in his spare time until it was able to provide him with a livelihood.

Amongs others, he has written for, and had his work performed by, are Dame Judi Dench, Billie Whitelaw, Jane Lapotaire and Michael Williams. Tinniswood’s second wife, the actress Liz Goulding, performed and inspired many of his works.

His oral cancer was the result of 40 years of pipe smoking. After four years of treatment he had radical surgery to remove his larynx and some of his tongue, resulting in the loss of his voice. He subsequently had an electronic voice-box fitted. Tinniswood moved back in with Liz Goulding, even though they had been divorced. She cared for him throughout his battle with cancer. He continued to work throughout his illness, saying that writing about what was happening to him was the only way he could cope.

Among his new plays were Croak, Croak, Croak and The Last Obit. “I am writing better than I have in my life,” he said shortly before his death.

Legislation that NYSDA championed in the hopes it would help alter the deadly outlook for patients suffering from oral cancer was signed into law in September by Gov. George Pataki.

The measure, which now becomes Capter 237 of the Laws of 2001, stipulates that dentists licensed in New York State must earmark no fewer than two hours of their mandated continuing education to a course devoted to the prevention and detection of oral cancer. This is a one-time requirement, which, it is hoped, will arm dentists with the knowledge they need to become a first-line defense against the scourages of oral cancer.

Within weeks of the bill’s passage, the New York State Dental Foundation learned it had been approved for a $150,000 grant from the New York State Department of Health to conduct a professional education/public awareness campaign to warn against the deletrious oral health effects of tobacco and tobacco products. A portion of these monies will be used to provide free oral cancer detection and prevention courses for dentists and hygienists.

Researchers plan world’s first phase III prevention trial for head and neck cancer

Norwegian researchers are planning the world’s first phase III randomised trial to prevent head and neck cancer.

They will use COX-2 inhibitors (coxibs) – a particular type of non-steroidal anti-inflammatory group of drugs (NSAID) – better known as a treatment for conditions such as arthritis. These drugs block the action of COX-2 (cyclooxygenase-2), an enzyme found mainly in inflammatory and immune cells and now suspected of playing a role in cell growth and genetic instability.

Dr Jon Sudbo, Consultant at the Department of Oncology at the Norwegian Radium Hospital in Oslo, revealed plans for the trial at a news briefing today (Thursday 21 November) at the EORTC-NCI-AACR Symposium on Molecular Targets and Cancer Therapeutics[1], in Frankfurt, Germany.

His team at the Norwegian Radium Hospital and colleagues from the University of Oslo Department of Oral Biology, have carried out a study to compare levels of COX-2 expression in three groups of people – 30 with healthy mucous membranes in their mouths, 22 with dysplastic (premalignant) lesions and 29 with oral cancer. The objective was to see whether the levels of COX-2 were linked to aneuploidy (aberrant numbers of chromosomes) in the DNA, indicating a genetic risk marker for cancer. The results are being presented for the first time at the Frankfurt conference.

“We found that COX-2 expression was up regulated from healthy to premalignant lesions and to cancerous oral mucosa,” said Dr Sudbo. “There was COX-2 expression in one healthy patient (3%) but all the healthy group had normal DNA. Among those with cancer 26 (88%) had COX-2 expression and 25 (94%) had aneuploidy. But, most notably, we found that of the 22 patients with dysplastic lesions, COX-2 was exclusively expressed in a subgroup of nine (41%) who we identified at high risk of cancer by the aberrant DNA in their lesion. Of these nine patients, we followed seven for at least five years and six of those (85%) went on to develop oral cancer.

“This is the first time that it’s been demonstrated that COX-2 is up-regulated in high-risk oral lesions. So, this is also the first demonstration that it may be possible to use targeted coxibs to prevent oral cancer.”

Dr Sudbo said that oral cancer was ideal for investigating chemoprevention because it was normally preceded by readily detectable lesions that can be identified and monitored without very sophisticated equipment or procedures.

“Typically, there is a lead-in time of five to 10 years between the occurrence of dysplasia and the development of cancer, so there is ample time to intervene with preventive treatment.

“Quite frankly we regard both the study and the forthcoming trial as a significant development, whatever the results turn out to be. With few and notable exceptions, treating manifest cancers is not an optimal approach to this group of diseases. Treating precursor lesions is a much more attractive approach, mainly because the complexity of the disease in early stages is not as pronounced as in more advanced stages.”

He said that most approaches to chemoprevention have failed and this was probably because reliable identification of high-risk individuals had not been possible. The Norwegian Cancer Society had therefore up to now had a “wait and see” approach to chemoprevention.

“Now we have identified risk markers this has changed, at least for oral cancer. The Norwegian Cancer Society is funding the trial with the Norwegian Radium Hospital as the primary investigating site. Our randomised trial, using celecoxib, will involve patients with aneuploid white patches in their oral mucosa. Our target is to recruit 350 patients and we expect the trial to last five years and to follow our patients for 10 years.”

Dr Sudbo said that head and neck cancers shared common risk factors with lung cancers. “An interesting spin-off will be to see whether the use of coxibs for preventing oral cancer will also influence the incidence rates of lung cancer. Selective coxibs have already been shown to influence the role of colon polyps,” he added.

A tiny, silicon laboratory on a chip that could test patients for cancer and other harmful diseases while they wait to see the dentist is being developed by a multidisciplinary team of researchers at UCLA.

Painless, noninvasive and cost efficient, the device could detect evidence of cancers before even the best-trained clinician would spot them, according to David Wong, Director of the Dental Research Institute at UCLA and principal investigator.

Researchers at the Henry Samueli School of Engineering and Applied Science bring expertise in nanotechnology and microelectromechanical systems (MEMS) to the project. Chih-Ming Ho, professor of mechanical and aerospace engineering and Carlo Montemagno, who chairs the bioengineering department, are among a team of engineers. The project is funded by a $4.2 million grant from the National Institutes of Health.

“We are integrating microtechnology, nanotechnology and microbiology to build a new class of devices for pre-cancer and oral pathogen detection,” Montemagno said. “Because it would provide inexpensive, rapid, early detection of oral cancer and pathogen,” Wong said, “it is technology that could take us to the next level of patient care.” Early detection of cancer and pathogen is frequently cited as one of the best means of surviving cancer and oral infectious diseases.

“Patients are often uncomfortable having their blood drawn,” Wong said. The process requires trained technicians and exposes the patient and technician to possible contamination by infectious agents. This device would eliminate both the patient discomfort and danger to health care providers. In addition, having all the technology needed to perform the test on a single chip would reduce both the time and cost of analysis, making it available to a larger group of people.

According to Montemagno, sensors on the chip would test the patient’s saliva for certain protein markers that signal the possible presence of oral cancers or oral pathogens. The technology also opens the door to even more sophisticated screening, Montemagno said. Researchers have identified numerous protein markers whose presence may signal possible cancer. Current tests, however, are far from definitive. They only serve to alert physicians to the possible presence of cancer. Invasive procedures such as biopsies must be done to confirm the test results.

“In follow up studies,” Montemagno said, “we want to look at using saliva and other bodily fluids to do multidimensional screening.” By constructing a chip that will look for a “whole suite of biological markers,” Montemagno said, researchers may be able to identify certain collections of markers, or signatures, which can be compared against those in a database containing similar signatures, known to be associated with certain cancers at different stages of development. Collecting these signatures may allow them to make diagnoses with “a high level of accuracy — hopefully before we’re able to visualize them.” “We are hoping we will be able to look at all the clinical signatures — perhaps as many as 100 at a time — as cheaply as what it costs to do a single test today,” Montemagno said.

Wong described the cooperation between the dental and engineering schools on the project as a “perfect marriage.”

Also participating in the research are Benjamin Wu, assistant professor of bioengineering; Wenyuan Shi, professor and Fengxia Qi, assistant professor, both at the UCLA school of dentistry; Paul Denny, professor of dentistry at USC; Richard Jordan, associate professor at UCSF and Bruce Baum, branch chief at NIDCR.

Ho is also Associate Vice Chancellor for Research and holds the Ben Rich-Lockheed Martin Chair in Mechanical and Aerospace Engineering. Montemagno holds the Roy and Carol Doumani Chair in Biomedical Engineering.